Obamacare and the cost of gridlock

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Private corporations exist to make money for their owners, and it would be foolish to count on them to view serving the health care needs of the poor and the sick as a higher priority.

The Affordable Care Act, aka Obamacare, is too complicated and too expensive and still leaves too many Americans without health insurance, but it has still done more good than harm by adding millions of formerly uninsured Americans to the ranks of the insured. About 20 million Americans are now insured through the various provisions of the ACA, and recent studies indicate that those millions are healthier, less likely to have medical debt, and more likely to get preventive care as a result of the program.

The Republican goal of repeal is also not possible unless Republicans get control of both houses of Congress and the White House, and even then, I wonder if they would actually have the nerve to do it, assuming it would throw millions of Americans out of the ranks of the insured. Republicans claim to want to “replace” it, but have never put out a sufficiently detailed vision of their replacement that can be analyzed and scored according to how many winners and losers it would create. If they come up with a way that covers more people and costs less, I’m all ears.

In addition to trying to repeal the ACA, Republicans have also tried to sabotage it. Although 31 states, including some with Republican governors, have exercised the Obamacare option of expanding the eligibility for Medicaid coverage, 19 states blocked the expansion — all of them because of Republican resistance. That leaves millions of near-poor Americans uninsured. Here’s a point I don’t hear made often enough:

Since the vast majority of the cost of Medicaid is paid for by federal taxes, the states that refuse the expansion are still paying their share for the expansion in the other states, while depriving their own uninsured of the advantages. That’s not only mean-spirited, but economically self-punishing. Try to imagine a state that would deny Social Security benefits to its own elderly, while everyone still working in the state continued paying their FICA payroll taxes to support the benefits of retirees in other states. Crazy.

So the ACA struggles on, to be the best version of itself it can be, under those circumstances, and with frequent setbacks, such as the recent announcement by Aetna to cut back its participation in the program, pulling out of all but four states. This follows similar pullbacks by two other health insurance giants UnitedHealth Group, and Humana. According to this New Republic piece, Aetna’s pullback is a retaliation against the federal government, which had blocked a proposed merger between Aetna and Humana on antitrust grounds.

It’s possible to overstate the impact of these withdrawals from the exchanges. Although the companies are large, their role in Obamacare was not that big. Aetna, for example, represented about eight percent of the ACA market. Private corporations exist to make money for their owners, and it would be foolish to count on them to view serving the health care needs of the poor and the sick as a higher priority. I suppose the question is whether a system that relies so heavily on maximizing private profits is the best vehicle for serving the health care needs of the rich and the poor, the sick and the well.

Former Labor Secretary Robert Reich, now a professor of public policy at Berkeley and a big-time Bernie Sanders backer, nonetheless seized on the Aetna cutback to make the argument that we would be much better off with single payer. Here’s the guts of Reich’s argument:

The problem isn’t Obamacare per se. It’s in the structure of private markets for health insurance – which creates powerful incentives to avoid sick people and attract healthy ones. Obamacare is just making the structural problem more obvious.

In a nutshell, the more sick people and the fewer healthy people a private for-profit insurer attracts, the less competitive that insurer becomes relative to other insurers that don’t attract as high a percentage of the sick but a higher percentage of the healthy. Eventually, insurers that take in too many sick and too few healthy people are driven out of business.

If insurers had no idea who’d be sick and who’d be healthy when they sign up for insurance (and keep them insured at the same price even after they become sick), this wouldn’t be a problem. But they do know – and they’re developing more and more sophisticated ways of finding out.

It’s not just people with pre-existing conditions who have caused insurers to run for the happy hills of healthy customers. It’s also people with genetic predispositions toward certain illnesses that are expensive to treat, like heart disease and cancer. And people who don’t exercise enough, or have unhealthy habits, or live in unhealthy places.

So health insurers spend lots of time, effort, and money trying to attract people who have high odds of staying healthy (the young and the fit) while doing whatever they can to fend off those who have high odds of getting sick (the older, infirm, and the unfit).

As a result we end up with the most bizarre health-insurance system imaginable: One ever more carefully designed to avoid sick people.

Sanders managed to demonstrate that it’s possible to openly advocate for single payer and still win a lot of Democratic primaries, not just in Vermont. But there are a lot of Americans who aren’t Democrats and a lot of Democrats who accept, at least as a political reality, that we can’t have single-payer in America, and even in within the Democratic electorate, Sanders lost to Hillary Clinton, who has never favored single payer.

(In case you forgot this, Barack Obama, when he was coming up politically, described himself in 2003 as a “proponent of a single-payer health care system.” By the time he was running for president in 2008, he preferred to say that if he was designing a U.S. health care system “from scratch,” single payer would be the way to go, but to switch from what we have to single payer would be “too disruptive.”) He eventually took to saying that he had never favored single-payer, a statement that got him a rating of “false” from Politifact.

Before Obamacare, comparing the United States to other major wealthy nations of the world, the U.S. had the most expensive health care system, the largest portion of its population lacking health insurance, and the worst or among the worst health care outcomes. For example, over recent history, the United States never cracked the top 25 nations for average life expectancy and never compared with the world leaders in reducing deaths by preventable diseases. Because of those measures, those who constantly tried to declare the pre-Obamacare U.S. health care system to be the best in the world were engaging in a denial of reality that could only be described as willful self-blindness.

Some of those measures have gotten a bit better in the four years since the 2012 Obamacare rollout, most especially the sharp drop from 18 percent to 11 percent in the share of Americans without health insurance. That would drop still further if those red states that have rejected the Medicaid expansion would accept it. Here’s a Gallup chart showing the drop.

The uninsured rate varies so dramatically by state that the disparities are jaw-dropping. Massachusetts has the lowest uninsured rate at 3.5 percent. Minnesota is fourth lowest at 5.8. Texas is highest at 22.3 percent. Yes: 22.3 percent. And there are 26.5 million Texans; it’s our second biggest state.

Massachusetts and Minnesota were much lower than Texas before Obamacare of course, but both states also accepted the Medicaid expansion and created a state-run health insurance exchange which further reduced their uninsured population. Texas did neither.

But, four years after the rollout, the United States still has the most expensive system in the world, one of the highest uninsured rates, and some of the worst health outcomes by any of the appropriate measures of overall health. That’s not the fault of the ACA, which is helping us close some of the gaps. And the explanation for the poor health of Americans is not entirely about the health care system either. But you would have to engage in some pretty serious cherry-picking to find any measures that contradict those generalizations, or you have to focus only outcomes for the affluent and the shrinking pool of those with particularly good employer-subsidized health care plans.

Here’s a recent ranking of nations by life expectancy, in which we come in 43rd. Canada, which we normally don’t think of as a crazy socialist country, has single-payer and comes in at 18. And spends far less than we do, per capita, on health care. I’m not saying life expectancy is the one best way to judge the efficacy of a nation’s health care system. And there are many complicating factors. But the U.S. system doesn’t do particularly well on any of the measures other than costliness, where we’re number one in the wrong direction.

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Veteran journalist Eric Black writes Eric Black Ink for MinnPost. His latest award is from the Society of Professional Journalists, which in May 2017 announced he'd won the national Sigma Delta Chi Award for online column writing.

Comments (66)

“…Since the vast majority of the cost of Medicaid is paid for by federal taxes, the states that refuse the expansion are still paying their share for the expansion in the other states, while depriving their own uninsured of the advantages. That’s not only mean-spirited, but economically self-punishing.”

Better systems don’t HAVE to be government-run, but they tend to be because the profit margin is nonexistent, as it should be. “The Healing of America,” by T. R. Reid, documents – documents – several health care systems in other industrial countries (including Canada, if memory serves me correctly) that get far better outcomes, at far lower cost to the individual and to the public at large.

American health care, as a system, is a disgrace. We have some wonderful practitioners, but the system has increasingly been overtaken by the corporate mind-set exemplified by the line under the photo that leads Eric’s piece: “Private corporations exist to make money for their owners, and it would be foolish to count on them to view serving the health care needs of the poor and the sick as a higher priority.” Anyone who has had to actually deal with a health insurance company for virtually anything beyond the most routine checkup knows that line to be true.

Rhetoric about “faceless government bureaucrats” determining your health care can – and should – just as easily be about “faceless insurance company bureaucrats.” And – unlike the government employees right-wingers like to belittle so often – those insurance company bean-counters are rewarded for minimizing your benefits so as to boost the bottom line of their corporation. And, I might add, they’re not accountable to the public.

While ACA has done a remarkable job creating better access to healthcare for millions of people, it completely and totally failed to put ANY appropriate cost control measure in place nor did it put any responsibility on the patient to seek care at the most appropriate level.

Patients showing up in ER’s because its “convenient” rather than going to the clinic. Patients coming back to the clinic multiple consecutive days because the “drug is not working” even though they are told it will take a few days for the drug to reach therapeutic dose. There are millions of examples like that. Each one requiring reams of documentation by various healthcare practitioners and support staff mandated by law. And we wonder why fewer young adults are entering the field of medicine.

Costs are spiraling out of control and sooner or late the entire system will collapse on itself. Hopefully whatever replaces it will have some cost controls that reinforce the patient’s responsibility to get care at the most appropriate level.

(it will save you $2,500, you can keep your Doc and the pool of pre-existing condition patients will be offset by healthy 26-45 year old enrollees) it was doomed from the start by the different folks who wrote the bill. First the lobbyists put in exceptions to the bill so they would keep their power of horse trading this for that with elected officials. Second, Obama and congress had the insurance companies get in bed with them, promising millions of new paying clients being forced into the exchanges by law (didn’t happen) exchanges were flooded with subsidized folks and pre-existing condition people, driving up costs of folks not getting subsidized. Third, in order to try to keep premiums down deductibles sky rocketed. Defaulting on medical bills are rising because the insured can’t afford to pay the $5,000 to $10,000 deductibles. As Pelosi so famously said “you have to pass it to find out the goodies in the bill”. Well we passed it and it is filled with so many carve outs it was doomed from the start and caving in on itself.

the number one obstacle you have to over come is our health care delivery system (Mayo, Allina, Fairview,etc.) No way will they tolerate the archaic fee schedule Medicare has now. Medicare undercuts their fees and the health care system shifts that loss on to those on private health plans. You think insurance companies are the enemy? Our health care providers are way more powerful and have plenty of friends in both parties, not just one.

no where did I say they didn’t take medicare patients,…what I said is the providers hate the fee schedule/reimbursement as it is way below what they see as fair. They increase the cost of care to those under 65 to compensate for the losses from medicare patients.

It shows that in the case of average practice revenue for orthopedists, the industry claim (which you have swallowed) that orthopedists are losing money or being turned into low-paid workers – is BOGUS!!

Orthopedist’s median net earnings after expenses in 2011 was $ 514,000 with typical distribution of revenue (i.e., payer) sources, about 1/3 of which were from Medicare schedules.

For an orthopedist whose SOLE payer was Medicare, the net earnings would be $ 411,000 – about $ 100,000 less.

This is the factual background to the industry’s wailing and moaning that they suffer so greatly, even lose money, on Medicare payments.

So while I do see the industry’s complaints, which you have repeated in multiple posts here, the truth is they make a profit on Medicare payments – not as much as they’d like, but a profit.

Those tears in the eyes of the health care industry spokesmen are CROCODILE TEARS: pity the poor orthopedist, scrimping by on $ 411,000 net income. My eyes are dry.

one little slice of the pie, much bigger in other specialties, Bottom line is if you believe we should equally share all resources and no one gets a nickle more than the next guy no matter how hard they work, then there is no point to discuss further.

If you actually read the comments from practicing physicians who commented on the biased blog that you posted, you’ll see that you conveniently picked a specialty that does get paid well enough to survive. What you and others who blindly believe USP will work ignore is that the overall reimbursement rate is so low many providers will not be able to provide the high quality service Americans have come to enjoy, which is precisely why USP won’t work. If it were to come to fruition, the quality would drop so low that there would be a major push to get rid of it. The only reason why USP would remain cheaper than the current system is because it reimburses providers at less than the cost of providing the service. The ACA has worked to the people who didn’t have insurance and now get free or insurance at less than cost of providing it. But it is still being floated by taxpayers and is adding to the debt.

Deductibles are high so that savvy shoppers will compare prices and pick the best bargain when they need care. Consumer Directed Health Care is the wave of the present. Is there a way to compare costs? Yes, private companies are able to tally that information and charge you for cost comparisons that they do not guarantee are accurate. The hospital cannot tell you your costs until after your insurance claim has been processed.

You might want to get a Health Savings Account with that High Deductible Health Plan because we had a national town hall meeting and all decided that we do not want to be like civilized nations and commonly share all medical costs in a national pool. It is everyone for themselves. A Health Savings Account can be paired with a HDHP as a tax-free way to save for your and your family’s future and current medical expenses. Don’t ask a health beat reporter what it is because they don’t seem to have ever heard of it. (Not you, Eric. That Strib guy.)

The idea is that the money you “save” by paying a lower monthly premium will be deposited into your HSA. I personally have never paid less for something and had money appear in a savings account as a result, but the idea is out there that it will work that way. Maybe it will, but somebody has to explain the process to health consumers.

You’re saying we are worse off now than before Obamacare? While this is solidly supported by right wing apocryphal stories, the facts are different as described by Eric above.

Read Heritage 218 on healthcare and you can clearly see who invented Obamacare principles. Look at Newt’s Hillary Care alternatives and you see the next attempt at applying ObamaCare. Move on to Mitt’s MA healthcare and you get to V3 of Obamacare.

The right’s aversion to Obamacare is 100% political in origin and practice. IT REMAINS THEIR IDEA IN THE FIRST PLACE. They were too ignorant, hostile and uncooperative to do the smart thing in 2009: take credit for it, pass it and then fix it as needed: they could have said they successfully waylay-ed Democratic single payer plans through applying a 25 year old conservative idea. DECLARE VICTORY AND GO HOME.

If Republican politicians cared one tenth as much about their country as their political ideology this would have been long behind us. Instead they will soon be queuing up for their fiftieth ridiculous Obamacare Repeal vote. And it is ridiculous acts like this that has built a level of distorted reality for Republican voters that allows someone as totally unqualified as Donald J Trump to be their party’s leader and standard bearer. The ultimate reaping what you sow.

We agree with Heritage that the differences between its original vision and the version enacted into law are not trivial, and are enough to undercut the president’s effort to secure a Heritage Foundation seal of approval for his bill. But the president helped his case by wording his statement with extreme care. Intentionally or not, he gave himself subtle linguistic running room by saying that “a lot of the ideas” for the exchange came from Heritage, including the concept of “just being able to pool and improve the purchasing power of individuals in the insurance market.” Even if not all of the ideas in the two plans are identical, we feel that it was fair of him to say that “a lot of the ideas” are in common, including the notion of pooling. So we conclude that the president’s statement qualifies as Mostly True.”

Our per capita spending is about 50% more than the next next nearest country – and while that money covers everyone, our money doesn’t. No way that anything we could do that is less than revolutionary that would bring down our costs.

If you don’t cover illness, it gets worse and unless he person dies before getting care, care with more advanced illness is more expensive. In order words, our system, which many still believe is exceptional, is mostly an exceptionally stupid way to provide a life-death services. Too expensive, too much profit, too much care and terrible outcomes, particularly for those without insurance or regular medical care.

However, ours is the most profitable healthcare sector in the world. As long as the wealthy get premium care and high return on investment they wll block any meaningful reform.

Obamacare extends coverage to the poor, but really only as long as high profits can be had. Insurance companies are really only interested in profit, not in changes to improve access, efficiency, clinical quality or outcomes.

The profits go away, and insurers and many providers walk away, leaving many people without coverage and care. Healthcare should be driven by patient need and clinical effectiveness. It should be completely dependable, not limited to only those oeople seen as worth serving.

was doomed from the start, too complicated and too many moving parts and too many bold but unattainable promises…the dems knew when it failed they would universally blame insurance companies and not their own lousy, poorly thought out law. Thanks for confirming that….

and really? No blame at all for our humongous, uncoordinated, profit driven and extremely power health care system? good luck getting single payer past them with that low ball fee schedule they despise.

To get to a one payer system. That has always been the goal by the libs.
Design the system to not be the best so partners drop out. Then the government, in it’s infinite wisdom, has to step in.
The problem is, no one is in it because the cost is so astronomical. Then the people have to pay. That’s what the Repubs have been saying all along, even before the ACA was ever implemented.
And since when has the government, especially those that have never worked in the private sector, ever overestimated the cost of anything???

You simply looked at premiums which of course have gone down by less than pre-ACA because pre-ACA you could get a $500 annual deductible or *gasp* a plan with no deductible. But post ACA the average deductibles are thousands and thousands of dollars which helps moderate premiums.
So yes you are correct in that premiums are not rising higher but that’s because the deductibles have skyrocketed.

… to hear ACA opponents complain about deductibles. Because what we were told in the Bush administration by Republicans when it came to health care is that people weren’t paying enough out-of-pocket for their health care, so they weren’t incented to become better consumers. They liked the idea of high deductible plans and gave us HSAs to help pay for it. And whether or not one wants to argue to the extent the ACA bears the structural imprint of Heritage or Romneycare, the actual plans being offered very much fit the sort of plans that Republicans loved to talk about a decade or so ago. Most of the plans on MNSure today fit — plans with high deductibles and they come with an option to open a HSA.

While the phrase “too big to fail” has been used about financial institutions, it is a phrase that is also applicable to the health-care industry.

17.1 percent of GDP is the healthcare expenditure in the US as of 2014. Compare this with a world average of 9.9 %, a European Union average of 10%, and a full 5.2 percent more than Sweden (11.9%) which is the closest fully-developed country.

The insurance industry loop requires an extraordinary amount of paperwork (digital these day, but still time-consuming.) I have had my doctor have to stop to look up coding during a visit, when the correct response to a patient’s problem should be whatever the doctor judges to be best. Single-payer would eliminate that kind of tap dancing, and savings could be used for actual healthcare. We also need to allow the government to negotiate with drug companies for the best prices – the pharma system we have now (pay what we ask or else) is a national disgrace.

haven’t had much experience with medicare recipients or their claims have you? they don’t exactly rubber stamp every claim or reimburse docs adequately. Our healthcare system would not let everyone be covered on a medicare system, they have too much to lose and medicare provides the same headaches as the private insurance market. It is not wise to let our providers go unchecked either.

This outcome was to be expected when only liberal progressive Democrats write and then pass the Bill without one Republican vote. The Democrats own it and cannot shift the blame for a costly, cumbersome and ineffective ACA.

I lost my retiree health care due to the ACA. Yes I’m bitter and angry!

“The Democrats own it and cannot shift the blame for a costly, cumbersome and ineffective ACA.” Sometimes, public policy is about more than assigning blame or playing “gotcha!” Sometimes, it is about trying to accomplish something for the good of the country.

Were the Republicans willing to work with the Democrats to pass a bill? My recollection is they were bent on making health care President Obama’s “Waterloo.” They had no alternative to present, so they just sat and sniped, and that pattern continues: Nothing to offer but complaints.

Now I can see some upsides to ACA, but it seems many people are resistant to acknowledge how much this program has cost most of us workers.

I mean my self employed friends are paying much more than they did before, we all lost half of our Medical Flex Spending amount when it went from $5,000 to $2,550 and you are not the first person I have heard regarding a loss of benefits.

I see pros to single payer, but I see more cons. One can not implement price controls without some serious negative consequences…

The question I have is 1/3 of Americans are obese and 1/3 are over weight, if one wants to reduce our healthcare costs… How do we change this severely?

ACA has already mandated that everyone must carry health insurance, that they will be fined if they don’t, subsidizes the premiums for lower income folks (tay payer funded), made health insurance plans visible and expanded Medicaid (tax payer paid for health insurance) in many states.

The reason the ACA didn’t finally pass until 2010 is because Obama spent the entire summer of 2009 seeking bipartisan support via the “Gang of Six” on the Senate Finance Committee. He waited and waited and waited until Grassley finally said that there was no bill that Republicans would support.

The problem I’ve seen with the whole health care debate is that most our economists in the US are basically dyslexic when they try to analyze the proposition. US economist are nearly completely trapped in neo-liberal/market based mentalities that distort rational thinking.

The fact is that Medicare For All (MFA), i.e. expanding Medicare Coverage to everyone and making THAT coverage completely comprehensive (no doughnut holes, complete medication coverage, etc.) is clearly the best way to provide the highest quality health care and universal coverage that is economically sustainable. The ONLY reason we didn’t move to this system decades ago (recall this was actually the plan back in the 60’s Medicare was created) is that our political and economic elite are invested in the existing system.

Despite MFA’s obvious simplicity and economics, and despite its popular appeal, our elite and those trapped in elite mentalities keep declaring, contrary to all evidence, that MFA is politically or economically unfeasible. Eric points out for instance that Sanders’s found some success with his MFA proposal among democratic primary voters but doubts it could find wide appeal. The truth is that right now a clear majority of Americans (58%) http://www.gallup.com/poll/191504/majority-support-idea-fed-funded-healthcare-system.aspx support a switch to single payer system. The largest single block of voters are now independents who support the proposal and those who staunchly oppose MFA are a clear minority (reactionary republicans) who are represented by a party that’s imploding. It’s like being trapped in a episode of: “The Simpsons” where everyone is saying solar power would be nice but the laws of physics preclude capturing the sun’s energy.

There are two obvious facts about:”gridlock” that everyone needs to remember. 1) Gridlock is an artificial obstacle that always collapses eventually. 2) Gridlock did NOT block single payer, the elite blocked single payer. Elite democrats like Hillary Clinton wouldn’t even consider a public option let alone single payer. If the democrats were in fact the party they claim to be, they would have had the votes to pass MFA and the guts to defeat republican filibusters. We could have had MFA and we would have been way way way better off for it. MFA wasn’t blocked by immutable laws of political reality, it was blocked by the political and economic elite. This isn’t “incrementalism” its flat out obstruction.

One of the most bizarre features of commentaries about MFA is the assumption that the current gridlock is permanent despite the obvious collapse of the republican party as if political power in the US NEVER changes hands. The truth is that the illusion of gridlock services the elite by giving the democrats an excuse for failure. Even when they’re in power, even when they run the table, they refuse to propose obvious and workable policies like sustainable tax rates, MFA, sustainable energy and environmental policies, etc. they claim they don’t have the votes to move the agenda forward but the truth is they don’t really want to move the agenda forwards because that would not be an elite agenda. Hillary Clinton is the poster child of this kind of democrat which is why she’s so unpopular and distrusted. Trump has positioned himself in opposition to the republican elite but he’s just as disliked and distrusted because his proposals are simply daft.

There is not enough money in the economy to pay for MFA at a rate that won’t seriously deteriorate our current health care delivery system. It is an easy system to try to emulate, but as noted above, the only reason why providers even put up with accepting Medicare and Medicaid patients is that they can squeeze the balloon and project the losses from the government reimbursement rate onto the private insurance market.

Truly, I don’t think folks here understand or are willing to accept that. Medicare may cover the variable costs, but I really don’t think it is covering the fixed costs and R&D. And I don’t know about you but I like nice buildings, beds and new equipment / treatment options.

I still remember my co-worker in England who waited ~30 minutes for the Doctor to find a stethoscope… After that they booked the next flight back to Chicago and had their child treated here.

It is true that most Americans don’t understand health care or health care systems, this is the source of the dyslexia. What’s really weird however is the fact that even our health care economists and other experts don’t seem to get it.

At any rate, Medicare’s mission is to pay providers for actual health care, this is no different than private insurers. Neither Medicare or private insurers pay for R&D and they all pay the bills be they for fixed or variable costs.

R&D funding is really a separate issue. R&D is funded largely by federal monies from the NIH and the CDC. Private dollars and sales revenue also pay for R&D but those dollars deliver increasingly poor health care. When Pharrm companies plow revenue into R&D they do so in search of profit; they dump billions into finding new iterations of existing meds that can be marketed as “new” until the patent expires and they start all over again. This is one of the reasons we’ve been having vaccine shortages shortages of other basic meds that have been around for decades. To listen to Pharm companies and medical device makers you’d think they lose money on R&D but clearly they’re not, and no one ever gets to look at their books.

Now the balance of R&D funding has changed dramatically over the last decade or so. NIH (National Institute of Health) and CDC (Centers for Disease Control) budgets have been slashed by republicans and the sequester slashed them even more. Now more R&D funding comes from revenue and that’s driven up prices and corrupted the science (you may have heard about the recent kurfuffle about the epipens and the controversy at the U of M regarding unpublished resarch?). Privately funded research is subject to patent, copyright, and other various nondisclosure limitations. Public University research that used to be published as a matter of course when it was funded by the NIH is now confidential. The problem with confidential research is that confidentiality impedes discovery and distorts results. The whole point of having publicly available peer reviewed publications is that methodology and discoveries can be scrutinized, shared, duplicated, and expanded. When a scientist conducts three drug studies, two of which failed to establish a drugs clinical effectiveness, you want to see all three studies, not just the last one that produced positive results. When research is privately funded, negative results don’t get published or the study is killed before it can produce negative results.

The other problem with the decrease in public funding for research is that research is driven by profit motive rather than basic science or medical/public health necessity. We need a Zika vaccine for instance but private funding won’t materialize unless market research reveals a sufficient potential for profit. This is how we end up endless iterations of “new” allergy meds instead of lifesaving vaccines and other devices, medications, and procedures. How many different types of digial thermometers do we really need and do the “new” ones really give us better temps than the old ones? One thing we know for sure… the new ones cost $300 and you can buy the old ones at Walgreens for $29.99.

Finally, the more research is privately funded the more inefficient the science is. Nondisclosure and copyright protections mean that a lot of research is needlessly duplicated when scientists working on the same or related work can’t or don’t share results. This is one reason we’ve seen a divergence from research spending and research results in the decade or so. We’re spending more, but we’re not getting more or better results, in fact one could argue the contrary.

What we really need to do in addition to Medicare for All is restore and increase public funding dollars for research. Science is like anything else, you have to invest in good science to get good results.

Thank you Mr. Kulda, you’ve provided a perfect example of the kind of dyslexia I’ve been talking about. We’ve heard the argument that MFA is not economically viable, i.e. “there’s not enough money in the economy to pay for it.” The weird thing is that actual health care economists have made this bizarre claim.

Look: we know that we’re spending 20% to 30% more than we should be and more than any of our peers are spending on health care. We know that administrative costs for Medicare are 15% -20% less than private sector insurers. If we have enough money to pay for the current system why would we not have enough money to pay for a more efficient and less expensive system? If you look at this claim its based a series of bizarre assumptions that no reasonable economist would make. Basically anti MFA economist make an illogical claim that the only system that could and would control costs would actually increase costs by greater magnitudes than we’re currently experiencing.

Last Fall when a bunch of health care “economists” looked at single payer (for the first time) they concluded that MFA would ADD a couple trillion in new spending! They forgot to that MFA taxes would replace existing premiums (not be billed in addition to existing premiums) so they didn’t subtract the premiums from their calculations. It took a few weeks but they finally had to admit that they’d made a rather embarrassing mistake and re-issued the analysis showing that MFA actually decreases total costs and saves most families $2k to $5k a year.

They also made a bunch of assumptions about inflation that didn’t make any sense, for instance they assumed that MFA would increase the inflation rate or that current trends would NOT be affected by MFA buying and bargaining power. Providers already complain about low Medicare reimbursements so I don’t why you’d expect that lower reimbursements would increase costs?

Yet other calculations appear to assume that number of insured would actually increase rather dramatically when in fact we wouldn’t be creating new patients, we’d just be moving existing patients into Medicare. The only “new” patients would be all of the remaining 20 million uninsured, but you’d also be collecting MFA taxes from them so it’s a wash. And before you start complaining about the new tax burden on uninsured you have to remember they are uninsured because they can’t afford existing premiums, the MFA tax would cost far far less and would be affordable.

I think it’s pretty clear that these analysts aren’t very accustomed to doing work that really matters or that anyone really pays attention to.

We don’t have health insurance since we don’t have underwriting to determine premiums relative to cost. Employees or Medicare all paying the same premium by definition do not have health insurance. Retail underwriting is prohibited by the Affordable Care Act, so we have abandoned insurance but still call it that and think that way. Insurance is always for a loss over which we have no control. Rather than loss oriented, health is forward-looking and goal oriented. Are we saying that I have no control and can’t influence my health?

A single payer system is still a la carte retrospective payment. Why can’t I join a health system such as Allina, Mayo, Fairview or Health Partners and be eligible for care the way our children our eligible for education in school systems? We need to go back to the Group Health model. Given proper public parameters and policies, UCare and United Health Group could calculate my annual fee for any system based on risk, health history, moral hazard in health behaviors, income and assets. That could be fair and much cheaper to administer.

You CAN join Allina, Fairview, or Park Nicollet (PN used to be Health Partners) any time you want as long as you can afford the premiums.

The Group Health model failed (which is why it was replaced by Park Nicollet) because it couldn’t attract the number of patients it needed to produce the promised economy of scale.

Look, insurance premiums go up and health care suffers because insurance companies make money by delivering as little health care as possible in exchange for premiums… that’s how they make profits. Health care providers make money by charging as much as they can for health care regardless of quality. So a colonoscopy in the US costs twice as much as a colonoscopy in Germany even though the US colonoscopy is no better than a German one and doesn’t really cost any more to perform. The problem is you can’t walk away from colon cancer because you don’t like the price of colonoscopy’s, health care isn’t a consumer driven activity.

The advantage of Medicare for All is that profit is not a requirement, and the “pool” (i.e. EVERYONE in the country) is so large that as a payer it can push back against provider demands far more effectively, thus controlling costs.

Finally, I hate to be the bearer of bad news but I have to say that in fact you do have little control over your actual health. You can’t control the drunk driver that puts yo in the emergency room, or high blood pressure you’re genetically predisposed to, or the aging process, or your immune system, etc. This is why thousands of people with great diets, and excellent exercise regimes end up in clinics and hospitals every day. You’ve never been sick a day in your life… until you get sick.

is just that, speculation. The Congressional Budget Office projected the ACA would have 24M folks signed up for 2016, the real number is 11.1M, they are in the business of predicting. Single payer is just another progressive dream. Please show me a Govt program (not a law, an actual program that has a budget, takes in tax dollars and runs on budget and works). ACA is not working, could never work (numbers never added up, that did not make us opposed to it racists, it made us right about the math). Putting folks in charge of their own healthcare makes sense to me. I know there will be folks who do not take ownership of their own health by doing nothing and waiting for Big Brother Government to step in to take care of them. It then comes down to do you believe healthcare is a human right? I believe you earn your right to Government healthcare (military service, police, fire), I don’t believe just because you are an American citizen your healthcare is to be paid for by others. There should be a safety net for those who truly cannot take ownership of their health but not a hammock stretched out for every American who doesn’t care about their health and saving money to pay for it.

I know enough to understand no program is truly a one size fits all for everyone. There will be folks who just don’t care and expect others to take care of them, they will be left behind. Personal responsibility has to come into our public policies at some point. It will never get you elected, but it is something most of us were taught as children.

“Please show me a Govt program (not a law, an actual program that has a budget, takes in tax dollars and runs on budget and works).”

Medicare, Social Security, and Unemployment Insurance. I know you’ll complain about the Social Security crises so let me just point out that had congress not robbed SS dollars to pay for other stuff or at least paid back what they took, and raised the tax cap, the program is perfectly sound for decades to come. You don’t get good programs without paying for good programs.

Furthermore, any casual examination of history reveals far more private sector failures regarding revenue and service than government failures (in liberal democracies.)

It was the very same elected officials that you want to turn over 17% of our national income to with single payer Govt run healthcare. The very fact that elected officials raided the “lock box” should scare you as it scares me. The Government should not have ONE public sector failure, that is not their job. Their job is to make laws not get involved in startups or running businesses (that includes bailing out too big to fail, thanks Bush/Obama). Of course the private sector has more failures, we have a capitalistic system where regular citizens put THEIR own money up to start a small business (the engine of our economy), many don’t make it. When a private business fails (prior too big to fail) the owner of the business loses money, the banks or credit union that lent him the money loses out and some other business that had the same product does better. That is the way it is supposed to work…. The Government bailing out companies or picking winners and losers with PUBLIC money should never happen… That is called crony capitalism and it is destroying our country.

We live in a liberal democracy pursuing a more perfect union. We don’t live in a capitalist state pursuing more profits. Many have pointed out the fact that neither the term, concept, or even the word: “capitalism” appear anywhere in the Declaration of Independents, the US Constitution, or the Bill of Rights. In point of fact the Capitalism we know today didn’t actually exist when the nation was founded.

Our nation may have a capitalist economy, but the combination of public and private sectors has always been a feature of that economy and hundreds of years of experience has taught us that while each have their strengths and weaknesses, you can’t have one without the other. Twas governments not companies that fought the opium wars and cleared Indian country so that settlers, traders, and railroads could exploit the “markets.”

Even Adam Smith recognized the fundamental immorality at the core of capitalism and pursuit of profit (i.e. “greed”). Corporations are essentially sociopathic entities that are legally bound to deliver the highest possible returns despite any harm that might be inflicted. (Note the persistent failure to recall dangerous products, the dodging of regulations, and the practice of jacking up prices beyond reason such as with Epi-pens).

Governance without morality may be an interesting plot for a science fiction story but it’s no way to country or even a civilization. Ayn Rand offers us a dystopian nightmare pretending to be a libertarian paradise, capitalist fantasy pretending to be economics. It’s no way to run a country and it’s certainly no way to run a health care system.

currently have? Why can’t the private sector produce goods and services without the public sector (ur tax dollars) being involved? Are you saying the Government gives morality to corporations and private businesses? If you truly believe that then you have never ran a business, started a company, dealt with the corrupt tax code/regulations that the “moral Govt” throws at you. Over 75% of folks think politicians are not trust worthy but you claim Government gives morality to the “sociopathic entities” (business folks)…

Paul, where does it say in our constitution that public money should be invested in businesses that the Government deems worthy? That includes auto industry, coal, green energy and any other sector of our economy. I am beyond flabbergasted that folks believe Big Government instills morality into anything it touches. DC is a cesspool of corruption with lobbyists, politicians and the 10’s of thousands that live of the tax payers dollars.

On a final note why is pursuit of profit (greed) bad? Who do know starts a business to lose money and fail? In what world do you see folks get a loan, rent a space, buy inventory, hire employees, pay insurance on workers and business, pay heating/electrical for business to lose money? That whole ideology just baffles me and leads me to believe folks who say “profit is bad” has never ran a business.

Making a profit, that is, operating any enterprise in a manner to provide useful product, to employ others who are skilled workers/craftsmen rather than entrepreneurs, is essential to long-term stability.

The case you cite is “profiteering.,” to be sure. This particular instance is one of product without competition, no market force to prevent price gouging. We also have statutes regarding dysfunctional behavior, statutes generally founded in societal precepts of morality and ethics. Current information indicates forces are quickly at work to temper this gouge.

Without profit “margin,” no entity succeeds. In essence, corporations are not “sociopathic entities,” but “sociocentric;” otherwise, they would find no consumer interest in their products. Even our very many 501(c) corporations must make surplus to build reserves. They are “non-profits” under the IRS Code, not aloof to business fundamentals. If we correctly view contributions as a form of capitalization, as “stake holding” if not “shareholding,” we understand the strong influence donors have on management, sometimes more immediately effective than shareholders have on public corporations. In any case, these are all market forces.

Again, this line of thinking is simply magical thinking pretending to be universal principle. Governments obviously succeed without making profits, i.e. police, fire, DMV’s, Social Security, Health Departments etc. This idea that greed is the primary motive for all people in all endeavors is simply facile. Greed and profit and not magical entities that always produce the best outcomes… on the contrary.

While the mental gymnastics behind magical thinking may be impressive on occasion the facts remain, and fortunately the Great Recession not only popped some market bubbles but seems to have popped the bubble of magical thinking surrounding capitalist chauvinism.

Opinions regarding this topic serve little purpose without facts. Here’s a pretty straight review of major country health systems organization. This topic is also not one for political posturing, please.

Note that this review is as of 2013. Pick your own preference, but note the generally perceived appreciation of the German scheme (as typically bureaucratic as most things German always are).
Please also consider U.S. advances regarding revised protocols. To be current (since 2012-13 references), please honestly extrapolate ACA and other U.S. progress. This surely isn’t 1990. That premise is mute.

Thanks for the study, it’s had a lot of nice info. Don’t get too excited about US protocol revisions however because that may indicate that the US was further behind in it’s protocols to begin with. In other words you may be seeing higher revision numbers simply because our system needed more revision.

That is the foundation of reference here. Far too many of us seem to be driving too much in the rear view mirror. One point I thought not necessary to reiterate here is that of “cost” vs.”price.” Maybe that needs review, as well. Many margins have closed significantly due to IT efficiencies, system consolidations and intense scheduling regimes that seem optimal now, at least in my personal provider array.

The significant aspect of the German scheme (to me) is the Long Term Care (LTC) coverage mandate. I may try to pull that out of their financials, because LTC is a very different question. U.S. carriers have withdrawn from that market, simply because they cannot price premiums anywhere close to breakeven points. That’s too weedy for this discussion, in any case. We need to maintain focus on prevention and acute/chronic care models.

The biggest gain in efficiency that Medicare for All delivers is that it eliminates all the marketing and administrative duplication we currently have in crazy abundance. Oddly enough it also reduces huge administrative resources that private insurers currently devote to denying coverage.

I always marvel at the dyslexia of Americans claiming to be in control of their health care with their private insurance when in fact their insurance companies control their health care. Hospitals and doctors either spend hours arguing with insurance nurses about providing care or they simply submit to insurance dictates and provide the care insurance pays for. I remember when my doc told me he was going to have to start charging for the time he spend arguing with insurance nurses. This is one reason we ended up with the Lipitor fiasco, insurance companies wouldn’t pay for Provochal even though Lipitor was crashing livers and spiking type II diabetes (among other things).

Medicare has the leverage to drive down prices on a broad base, it doesn’t have to argue about paying for one medication or procedure instead of another. Your health care professionals can then focus on best practices rather than insurance company mandates. And since MFA would be nation wide and almost universally accepted by providers, you really would have complete freedom to seek whatever care you need wherever that that care is provided, without seeking pre-approval. You can’t go outside the “network” because the network is EVERYONE everywhere.

While better IT infrastructure in theory can reduce costs, in practice it doesn’t appear to do so. For one thing IT costs money, it’s a adding an infrastructure that wasn’t there before, and it’s not cheap. You also don’t get the same results in every health care setting, clinic or hospital. Part of the problem is a proliferation of mediocre or even incompetent health care executives. In the hospital that I worked at for instance the execs decided to use one system (EPIC) or the outpatient clinics and a completely different system for the inpatient system. This delayed full implementation for almost a decade and required two IT teams instead of one. In the end the hospital ended up with a two million dollar inpatient system that never really went live, they ended up scrapping it and using EPIC for both inpatient and outpatient.

So one hospital can spend $4 million and get a fantastic system and another can spend the same amount (even with the same consultants) and get something that barely functions depending on the executives running the hospital, or the proficiency of the consultants. There are also glitches in the technology itself. Instead grabbing a chart staff now push computer stands around and pay typists to take notes while they talk to patients. These things are supposed to be wireless connected to servers but those nodes can fail. I used to carry a stethoscope, and blood pressure cuff, and thermometer around to get vital signs. Now they have they these very expensive machines on wheels and stands that are actually more cumbersome to use. Those machines are supposed to connect wireless to the patients chart and drop the vitals right into the medical record. On a recent visit to a hospital in the East coast I was told the wireless wasn’t working so they had to manually go into the charts anyways. Not only that but those machines have to be calibrated on a regular basis to make sure you’re getting accurate readings, I never had to calibrate a blood pressure cuff and the equipment I used was way way less expensive.

What we should have done is created a federal program to guide the electronic medical record systems nationwide based on best practice. This wouldn’t gotten quality system into place despite mediocre executives and cost. It would have guaranteed system compatibility as well.

Many of these IT problems may shake out in the end but it could take decades. While we many not see huge savings with IT and EMR we can see a significant increase in health care quality for a variety of reasons.

Finally we to be clear on a few things regarding “prevention”. Too many people think that preventative health care will actually save money… it doesn’t. Health care is health care preventative or otherwise and costs money. Preventative health is all about performing tests and screenings and detecting and treating problem at earlier stages, which is good, but not cheap. It’s better to avoid major colon surgery but’s colonoscopy’s every five years aren’t cheaper. Once you take the low hanging fruit like type II diabetes off the table there really isn’t much there there in terms of savings. We know that detecting heart disease early can prevent heart attacks, which is a good thing, but decades of medication turn out to be just as if not more expensive than emergency treatment for heart attacks. Consider the fact that it doesn’t actually cost less to have twice a year visits to the dentist for 20 years than it would to fill a couple cavities over the same period of time.